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For Immediate Release

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Moving in the right direction: Fourth annual Minnesota Adverse Health Events report shows fewer errors for Allina and Minnesota

MINNEAPOLIS 01/17/2008--In a world as complex, fast moving and ever changing as health care, mistakes will sometimes be made. By studying the causes of past errors and comparing notes with others who have made similar mistakes, health care organizations can discover new ways to prevent such occurrences and make care safer, says Penny Wheeler, MD, chief clinical officer, Allina Hospitals & Clinics.

On Thursday, Jan. 17, 2008, the Minnesota Department of Health released the fourth annual Adverse Health Events public report. The report includes hospital-specific information about medical errors in 27 categories occurring from Oct. 7, 2006 to Oct. 6, 2007. All hospitals in Minnesota are required by state law to report this information. The goal of the report is to improve patient safety by studying the causes of medical errors, identifying common safety issues and facilitating collaborative solutions among hospitals.

Findings

This year's report documents 15 adverse events at Allina hospitals, down from 24 in the previous year's report. Across Minnesota, total reported adverse events have also decreased – from 154 in last year's report to 125 this year.

"Any adverse event is unacceptable," Wheeler said. "While the decrease is encouraging, I want to be clear that we must improve working together as a system to reduce any preventable harm to our patients. We are doing a better job of identifying and reporting these types of occurrences, and what we report and learn from, we can prevent. That is why this process is so important to advancing our safety and quality agenda at Allina."

Allina's safety agenda includes several long-standing programs, as well as new efforts, to address issues highlighted in the report and other safety concerns.

• Allina, with extensive participation from caregivers, continues to advance a Safe Site Surgery initiative, which aims to completely eliminate surgical mistakes such as operating on the wrong part of the body.
• Allina launched hourly rounding, a practice in which hospital nurses and other care staff work together to check on patients each hour and address any unmet needs. Research shows that hourly rounding can reduce patient falls and reduce skin breakdown.
• Allina's system-wide initiative to reduce falls is now in its fifth year. The program includes patient education as well as a rigorous evaluation process to determine which patients are at greater risk for falling.
• Excellian increases patient safety by enabling more efficient communication of patient information so that potential problems can be identified earlier.
• Allina is part of a statewide effort with the Minnesota Alliance of Patient Safety to prevent pressure ulcers (bed sores), including sharing best practices regarding turning patients, providing pressure relieving surfaces and identifying patients who are more at risk to develop pressure ulcers.
• Allina is adopting new protocols in collaboration with Safest in America for retained foreign objects in surgery and other invasive procedures.

"All of our efforts are focused on doing everything we can to reduce potential harm to patients," said Judith Napier, vice president, system safety. "Human beings will always make an occasional mistake. Our goal is to design systems and processes that substantially reduce the possibility that patients will be harmed by catching errors early."

For Wheeler, and for caregivers across the system, continuously improving the quality and safety of the care provided in Allina facilities is far and away their top priority.

"It is never easy to face your mistakes," Wheeler said. "But our values as an organization demand nothing less. The Adverse Health Events Report provides an opportunity to do just that and is one of the best tools we have to focus our efforts in order to improve the quality of care we provide."

More information on Allina's patient safety work is available on Allina.com/patientsafety.

About Allina Hospitals & Clinics

Allina Hospitals & Clinics is a not-for-profit system of hospitals, clinics and other health care services, providing care throughout Minnesota and western Wisconsin. Allina owns and operates 11 hospitals, 65 clinics and health care services, including home care, hospice and palliative care, oxygen and medical equipment, pharmacies and emergency medical transportation.